V12-04: One-stage reconstruction of obliterative distal anterior urethral strictures with circular buccal mucosa graft
VideoIntroductions and Objectives
Distal urethral strictures are common in adult men due to susceptibility of the distal urethra to trauma, infection, and inflammatory diseases. Reconstruction of distal urethral strictures is a challenge for creating both a functional and a cosmetic outlet. Substitution urethroplasty for obliterative distal urethral strictures generally requires a two-stage approach or a complex urethral plate reconstruction combined with onlay augmentation. We report our experience with one-stage distal urethral reconstruction using circular buccal mucosa graft (cBMG).
The data of 24 men (age: 25-72 years) treated with cBMG urethroplasty between 2001 and 2014 were reviewed. Patients were evaluated with AUA symptom score, uroflowmetry, and retrograde urethrography/voiding cystourethrography. The external meatus was involved and the stricture was confined to distal urethra in all cases. The etiology was iatrogenic in 9 and inflammatory in 15 men. Through a circum-meatal incision, the distal strictured urethra was dissected from the healthy glans tissue, and sectioned at the location of proximal healthy urethra. A rectangular BMG with 4 cm. length and 1 to 3 cm. width (depending on the length of the defect) was harvested. The BMG was rolled on a 24Fr urethral sound with its mucosa facing inward, and its long edge was sutured circumferentially to the healthy proximal urethral mucosa. Neo-meatus was then reconstructed with distal anastomosis of the cBMG circumferentially to the initial circum-meatal incision. Foley catheter was removed after 2 weeks. Postoperative data were recorded during an initial visit 7 days after urethral catheter removal and at 1st, 3rd, 6th months, then yearly thereafter. Preoperative AUA symptom score and Qmax measurements were compared with postoperative values obtained at the last follow-up using Wilcoxon sign test.
With a median follow-up of 36 months (range: 6 to 96), 19 (79.1%) patients were cured. One patient had early graft loss, 2 patients developed stricture at the proximal anastomotic site and 2 patients had re-stricture at the neo-meatus. Mean Qmax(ml/sec) increased from 6.9±5.2 preoperatively to 21.6±9.2 postoperatively (p=0.01), and mean AUA score decreased from 26.1±3.7 preoperatively to 7.8±3.6 postoperatively (p=0.002).
Our results suggest cBMG as a feasible alternative in one-stage reconstruction of obliterative distal urethral strictures urethra, since glans penis has a good blood supply that provides an efficient circumferential graft take.